Outreach to members while admitted inpatient or after inpatient or emergency department discharge to conduct focused transitions of care assessments.
Outreach to case managers for members that are admitted inpatient to assist with discharge planning as needed.
Complete self-efficacy and condition-specific screeners including behavioral health tools like PHQ-9, GAD-7, AUDIT, or DAST-10, to identify members requiring behavioral health programming.
Conduct in-person clinical exams if appropriate and collaborate with care team members to determine if a different intensity program placement is needed.
Conduct comprehensive medication reconciliation and address contracted and company-prioritized quality gaps, ensuring proper chart documentation and appropriate ICD or CPT coding as evidence of gap closure.
Triage referrals from the Population Health Partner for short term clinical interventions and chronic disease management.
Meet members in various community settings such as homes,shelters, or hospitals, serving as an extender of care team providers and performing tasks like administering injections, monitoring vital signs, and in-home medication reconciliation.
Review charts and data signals for potential transition to higher level of complex care management. Facilitate follow ups and hand offs to care team as needed.
Utilize care facilitation, electronic health records, and scheduling platforms to collect data, document member interactions, organize information, track tasks, and communicate effectively with the team, members, and community resources.
Success Metrics
Timely outreach to members and hospital case managers for transitions of care support.
Completion of focused transitions of care assessments, ensuring accurate medication reconciliation and follow up visits are scheduled.
Identification and timely escalation of members requiring higher-intensity programs or behavioral health interventions.
Completion of assigned queue tasks within established timelines.
Efficient management of multiple short-term clinical assignments without compromising quality.
Effective communication and collaboration with care team members, Population Health Partners, and community providers.
Job Requirements
Professional Experience & Knowledge
Education: Graduate of an accredited school of nursing (R.N.)
Experience: 3+ years of experience
Behavioral Competencies
Member Advocate
Mission Driven: Balances competing priorities by choosing the path that best aligns with service to members and inclusive processes.
Compassionate Care: Identifies and responds to member needs proactively and suggests improvements that enhance the member experience.
Business Acumen: Applies understanding of government-funded care to make better recommendations and improve processes.
Team Builder
Collaboration: Adapts collaboration style to build understanding and bridge communication gaps and encourages others to share ideas.
Team Effectiveness: Helps improve how the team works together through observations and feedback.
Engaged Culture: Highlights others' contributions and drives small but meaningful and inclusive actions to contribute to team morale, safety, and engagement.
Results Driver
Strategic Clarity: Helps peers stay aligned by translating broader goals into clear team action, identifies misalignment, and proposes solutions to bring clarity and focus.
Proactive Approach: Spots gaps or roadblocks early and proposes ways around them, demonstrating resourcefulness and persistence even when projects are ambiguous or difficult.
Accountability: Uses metrics and data to evaluat
Benefits
Health insuranceRemote work options
Additional Information
Job Description:
The Resource RN provides nursing support to members with low-acuity, short-term clinical needs. This role does not carry an assigned member panel; instead, the Resource RN works from a task-based queue to address targeted clinical needs. Responsibilities include providing clinical education, delivering focused interventions, and supporting care transitions following inpatient or emergency department visits. Care is delivered virtually and in person, as appropriate. The Resource RN also conducts chart reviews and evaluates clinical data to identify members who may require higher levels of care management or short-term clinical intervention.
Cityblockhealth · Tampa, FL